87TH LEGISLATIVE WRAP-UP
Medicaid Expansion By Cameron Holguin and Ida Vaziri
When it comes to hot topics in both politics and medicine, nothing turns more heads than the topic of Medicaid. One cannot simply bring up this topic without a debate ensuing. Yet, despite the complexity of this topic and the discourse that comes with it, Medicaid expansion and the large uninsured population in this country are topics that health care providers must address. Let's take a look at the complex and ongoing story of Medicaid expansion here in Texas. The debate regarding Medicaid expansion began over a decade ago with the passage of the Affordable Care Act. As a part of that original legislation, states were mandated to expand Medicaid eligibility to all adults under the age of 65 whose incomes were lower than 133% of the Federal Poverty Level. This provision was eventually made optional in 2012 following the Supreme Court ruling in National Federation of Independent Business (NFIB) v. Sebelius.1 Following this ruling, over a dozen states, Texas included, opted to decline federal funds for Medicaid expansion once the policy went into effect on January 1, 2014. Since then, 13 states have chosen to opt back into Medicaid expansion, with the most recent state being Oklahoma, which will implement its expansion on July 1 of this year.2 Texas remains one of 12 states who have yet to accept funding provided by the ACA. A 2020 report by Bush School Public Health estimated that $5.4 billion dollars are being left on the table by the Texas Government’s decision to not expand Medicaid.3 Bexar County could have received over $430 million if Texas had opted to expand Medicaid this year.3 It is estimated that these funds, along with the matching provided by the state, would allow for nearly 1.3 million Texans (101,000 in Bexar County) to become eligible for Medicaid.3 Texas has the highest uninsured population in the country, with 5.2 million Texans without insurance. This is over 18% of the population, more than double the national rate of uninsured individuals, which is 9%. It is estimated that expanding Med32
SAN ANTONIO MEDICINE • August 2021
icaid could save Texas $110 million over the course of just two years. Additionally, states that expanded Medicaid were shown to have fewer closures of rural hospitals and higher patient volumes and quality of care in rural hospitals that remained open. Texas has experienced the highest rate of rural hospital closure in the nation, with 15 hospital closures between 2010 and 2018.4 Texas has opted to continue denying Medicaid expansion, although recent polls have shown that approximately 70% of Texans support it. Additionally, 59% of Texans feel that the state isn’t doing enough to help low-income individuals receive the health services and coverage that they need. A few bills to expand Medicaid have been proposed in the legislative sessions since Texas opted not to expand, but they have not received the approval of some lawmakers. In 2019, Texas State Senator Nathan Johnson proposed Senate Joint Resolution 34, proposing an amendment to the state constitution to require the state to expand Medicaid eligibility per the ACA guidelines.5 This bill did not survive to the 2019 Legislative Session. Lawmakers who oppose Medicaid expansion argue that the state could develop its own system to provide health coverage to the uninsured that is both cheaper and more efficient than Medicaid. Attempts to build this system have caused buzz in the legislature along with the direct expansion of Medicaid. The first attempt to develop this system came in 2013. This by far would have been the most opportune time to create an alternative system, as it would have gone live just as the majority of the nation was expanding Medicaid through the ACA. This attempt, however, failed and Texas became one of the 19 states to not expand health coverage. Another attempt to create an alternative system came in the most recent legislative session when lawmakers proposed SB 117 and HB 3871. These bills received bipartisan support and would have provided Texas with a unique way to expand Medicaid while pro-
